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The Elephant In The Room When It Comes To HRT

Of the many medical options open to someone embarking on transition, it is probably hormone therapy which delivers the most benefit. You feel *much* better, some of the undesirable characteristics of what you are trying to leave behind go away, and you gain some of the characteristics appropriate for your gender identity. It’s no panacea, but life feels much better after HRT.

There are several routes to HRT depending on which medical practitioners you are seeing and which protocols they follow, but the most usual seems to be that you can access a hormone prescription after a stay on a waiting list for several years, a diagnosis of gender dysphoria, and a set time period of so-called “Real Life Experience”, or RLE, living in your chosen gender role. There is much to discuss about whether or not this route is appropriate or whether the role of psychiatrists is necessary, but that remains the way into HRT. It’s a process that can be extremely arduous, and for many of us it is the most difficult moment of our lives.

Because there are so many hoops to jump through to gain an HRT prescription, many people in desperation seek an easier path. Some of the well-heeled ones go to private doctors with more lax prescription standards, others simply become amateur endocrinologists and order their own hormone preparations over the Internet. These so-called self-medicators are numerous, by some estimations their route has become the de facto route into HRT as many patients self-med before starting their RLE and convert to an “official” prescription at the point their doctors deem them to qualify for it. Buying your own hormones online is risky even if it rests under a loophole in the law that saves it from outright illegality, so while it probably won’t get you sent to jail it does put you in the same territory as you would find yourself in were you to buy a dodgy pill from a bloke in a nightclub. It’s the standard warning that even with blood tests to monitor your levels you are still endangering your health, but it’s inescapable that people have come to grief this way.

The elephant in the medicine cabinet

We thus have a somewhat farcical situation in which access to treatment is made difficult to the extent that a significant number of patients are prepared to break the law to get their hands on it. Everyone knows this to be the case but turns a blind eye to it, the doctors pretend it doesn’t happen and just prescribe HRT to people doing it to get them off it, and some sections of the trans community display an astounding set of double standards towards people who do it. Desperate times breed desperate measures, and treating those members of our community badly because of their desperation is not the right thing to do.

With my slow train transition, I was luckier than some in doing my RLE. I hit the ground running having had facial hair removal and grown out my hair, a significant amount of part-time experience behind me. I would have liked to have had HRT on day one, but waiting for my prescription wasn’t as arduous as it is for some even though I’ve had my fair share of problems with dodgy endocrinologists messing up my dosage since then. Over the ever-growing number of years since though as I’ve got to know more slow transitioners I’ve found plenty whose path has been more broken even than my convoluted one. People who started self medicating and ran out of money to buy more, people abandoned by NHS practitioners, people taken off their HRT against their will. If you are a three-bags-full-sir two-year speed transitioner then you probably don’t even know these people exist, but if you do encounter any then it is inappropriate to be hard on them for their choice in hormone sourcing when it is their only choice.

Sometimes it’s even given me a quandary. When my dose changed and I ended up with a box of smaller patches I no longer needed, I held in my hands something that could be life changing for one of my excluded trans sisters. If you do not know the pain of having your hormones taken away indefinitely or worse still being left with a very low hormone level as I was for about a year at one point then maybe it’s easy to condemn me for having thought of passing them on, but if you can imagine for a moment yourself losing that HRT prescription then maybe you’ll understand.

Of course, if I had passed on a box of my old prescription, that would put me in a very dark place legally, right alongside that bloke selling the dodgy pills in the club because it’s definitely illegal to pass on a prescription. So though I came perilously close in thought, I hung on to any surplus I had in deed. Because, you know, it’s dodgy for me to give someone a box of known-quality NHS-sourced HRT but it’s perfectly acceptable to turn a blind eye while they order a box of questionable east-Asian contraceptive pills from the internet.

Pretending it doesn’t exist is absolutely pointless when half the patients are doing it

The real problem here is that a system so poor as to make ordering unknown-quantity hormones from the internet an attractive alternative for so many, is broken. Utterly, completely, and fundamentally broken. Pretending the elephant in the room doesn’t exist is absolutely pointless when half the people in the room are blatantly riding it. We need to have a very public conversation about the subject, and we need that conversation to be dominated neither by the overwhelmingly cis practitioners in the gender medical establishment nor by the echelon of privileged wealthy white middle class trans activists who would speak for us all based on their own narrow experience, but by the people involved. The broken trans people, the poor trans people, the trans people excluded from treatment. If you do not have a seat at that particular table you should not get a voice, instead you should STFU and listen.

There are some who would take the radical route of removing the psychiatrists entirely from the equation, but speaking personally it’s not a course of action I’d espouse. It’s a sad fact that among our number we do have people who need the services of a psychiatrist, assuming of course that the psych in question is both competent and prepared to do their job. But beyond a simple assessment that the person is trans, they should have no further involvement with their endocrinology. Definitely continue to support and monitor their mental health, because that is their specialism, but that’s it.

Meanwhile the other side of a trans patient’s care should be decided by those under whose specialism it lies. A specialist in endocrinology should make it their priority to have a newly-arrived trans patient on HRT at the earliest opportunity. Though there is an endocrinologist on the staff of every gender identity clinic, the experience reported by most trans patients is one of psychiatrists calling the shots over access to hormones, and of their recommending prescriptions and deciding dosage. You wouldn’t be happy to have a psychiatrist treat your cancer, so why on earth should you be happy to have one treat your endocrinology?

From the perspective of a trans patient it is difficult to escape the conclusion that the focus of the gender medical establishment in this context is not on the needs of the recipients of the treatment, but on those of the practitioners. The whole edifice appears as a construction with a focus not on relieving suffering but on covering the backsides of the overwhelmingly cisgender staff, and the roadblocks thus created have simply had the effect of creating a culture in which self-medication is an attractive option.

For those who do it, self-medication is an act of necessity. Perhaps for the broken system that has spawned it to be reformed, it needs to be reframed as an act of protest.